medicina Review A Narrative Review of the History of Skin Grafting in Burn Care Deepak K. Ozhathil *, Michael W. Tay, Steven E. Wolf and Ludwik K. Branski Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77550, USA; [email protected] (M.W.T.); [email protected] (S.E.W.); [email protected] (L.K.B.) * Correspondence: [email protected]; Tel.: +1-508-654-8246 Abstract: Thermal injuries have been a phenomenon intertwined with the human condition since the dawn of our species. Autologous skin translocation, also known as skin grafting, has played an important role in burn wound management and has a rich history of its own. In fact, some of the oldest known medical texts describe ancient methods of skin translocation. In this article, we examine how skin grafting has evolved from its origins of necessity in the ancient world to the well-calibrated tool utilized in modern medicine. The popularity of skin grafting has ebbed and flowed multiple times throughout history, often suppressed for cultural, religious, pseudo-scientific, or anecdotal reasons. It was not until the 1800s, that skin grafting was widely accepted as a safe and effective treatment for wound management, and shortly thereafter for burn injuries. In the nineteenth and twentieth centuries skin grafting advanced considerably, accelerated by exponential medical progress and the occurrence of man-made disasters and global warfare. The introduction of surgical instruments specifically designed for skin grafting gave surgeons more control over the depth and consistency of harvested tissues, vastly improving outcomes. The invention of powered surgical instruments, such as the electric dermatome, reduced technical barriers for many surgeons, allowing the practice of skin grafting to be extended ubiquitously from a small group of technically gifted reconstructive surgeons Citation: Ozhathil, D.K.; Tay, M.W.; to nearly all interested sub-specialists. The subsequent development of biologic and synthetic skin Wolf, S.E.; Branski, L.K. A Narrative substitutes have been spurred onward by the clinical challenges unique to burn care: recurrent graft Review of the History of Skin failure, microbial wound colonization, and limited donor site availability. These improvements have Grafting in Burn Care. Medicina 2021, laid the framework for more advanced forms of tissue engineering including micrografts, cultured 57, 380. https://doi.org/10.3390/ skin grafts, aerosolized skin cell application, and stem-cell impregnated dermal matrices. In this medicina57040380 article, we will explore the convoluted journey that modern skin grafting has taken and potential Academic Editor: Lars P. Kamolz future directions the procedure may yet go. Received: 4 March 2021 Keywords: skin graft; history; autograft; burn; dermatome; mesh; split-thickness; xenograft; CEA; Accepted: 7 April 2021 CSS; Spray-on-Skin; ReCell Published: 15 April 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in 1. Introduction published maps and institutional affil- “(A Spaniard) upon a time walked in the field, and fell at words with a soldier, iations. and began to draw (his sword); the soldier seeing that, struck him with the left hand, and cut off his nose, and there it fell down in the sand. I then happened to stand by, and took it up, and pissed thereon to wash away the sand, and dressed it with our balsama artificiato, and bound it up, and so left it to remain 8 or 10 Copyright: © 2021 by the authors. days, thinking that it would have come to matter; nevertheless when I did unbind Licensee MDPI, Basel, Switzerland. it I found it fast conglutinated, and then I dressed it only once more, and he was This article is an open access article perfectly whole.”—Leonardo Fioravanti [1]. distributed under the terms and conditions of the Creative Commons The above is an excerpt from the sixteenth century works of Leonardo Fioravanti Attribution (CC BY) license (https:// (1517–1588), a charismatic Italian surgeon, who was controversial in his time for his vocal creativecommons.org/licenses/by/ rejection of Galenic doctrine and credited with performing the first splenectomy on Italian 4.0/). soil [1]. Fioravanti was also the first in the western world to document the successful Medicina 2021, 57, 380. https://doi.org/10.3390/medicina57040380 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 380 2 of 28 reattachment of a severed body part, in this case a nose. The excerpt describes a 29-year-old gentleman named Signor Andreas Gutiero living in Africa, who, much to his own misfor- tune, chose to engage in a heated argument with a soldier stationed there. As described above, this interaction did not go well and left Gutiero breathless and detached from his nose. Leonardo Fioravanti happened upon this encounter and was able to achieve an outcome that would be considered remarkable for any time period, and certainly in his. Though this anecdotal story is not a true description of a skin grafting per se, the practice of tissue restitution lays the foundation for the development of modern skin grafting. Fol- lowing Fioravanti’s report, numerous similar descriptions of nasal restitution subsequently appear throughout the literature as criminal punishment with nasal disfigurement was a common practice in those days. Arguably, auto-transplantation of tissue to its own donor site is the precursor to cutaneous autografting. Burn injuries and their treatments are intertwined with human history dating back to the origins of mankind’s relationship with fire. In fact, the rich history of burn wound treatments predates civilization. Archeologists have found cave paintings depicting Neanderthal-man having treated burn wounds with plant-based extracts [2,3]. Numerous concoctions over the ages have been utilized to treat burn wounds. In the ancient world, the Ebers Papyrus (1500 BC) describes Egyptian physicians making salves derived from animal, plant, and mineral byproducts and combining their application with religious ceremonies to the Goddess Isis. Burn wounds were then dressed with bandages moistened with the milk derived from the mothers of male infants [4]. The Romans had a pharma- copeia of products to treat burn wounds, ranging from mixtures of honey and bran to cork and ashes [3]. For millennia, physicians have attempted to treat burn wounds with all manner of products and combinations therein, but were met with middling success due to the lack of scientific understanding about burn wound pathophysiology. Independent of burn injuries, the history of skin grafting followed a similar trajectory with limited success for several centuries due to a combination of inefficient tissue collection methods, inappropriately thick grafts, and a lack of understanding of the physiology behind skin grafting. It would not be until the nineteenth century on the wave of numerous medical advances in burn care that the Swiss surgeon Jacques-Louis Reverdin (1842–1929) and the English surgeon George Pollock (1897–1917) would first apply skin grafting techniques to the treatment of burn wounds [5]. Modern burn care is the result of numerous advances in wound care, understanding of burn sepsis pathophysiology, operative technology, and surgical technique. The single most significant advancement credited for heralding the modern age of burn care is the utilization of skin grafting after early wound excision first introduced in the 1940s [6]. Today, autografting of full thickness burn wounds is the standard of care, having a direct effect on time-till-wound-closure, and a substantial impact on morbidity and mortality for burn victims. In this historical review, we will trace the evolution of surgical techniques, the development of operative instruments and the advancement in physiologic knowledge about skin grafting through the ages. We hope to integrate a common thread of the lessons hard-learned by numerous exceptional surgeons in our timeline to best appreciate how the state of modern burn care came to be. Furthermore, the author hopes to explore techniques and cutting-edge technologies that are anticipated to play a significant role in the burn care of tomorrow. 2. Skin Grafts in Antiquity: 3000 BC–476 AD Facial mutilation was a common punishment in the ancient world and practiced in much of Asia and Europe. It was often performed by cutting off the nose or ear of victims as a punishment for crimes committed, but also served as a warning to other would-be wrong-doers. The silver lining of centuries of this painful and humiliating practice was that it inspired the development of skin grafting [7]. One of the oldest descriptions of nasal mutilation comes from an ancient Indian Sanskrit epic from 1500 BC, the Ramayana, in which Lady Surpunakha (Meenakshi), angry after being scorned by Prince Rama, attacks Medicina 2021, 57, 380 3 of 28 his wife Princess Sita. As punishment, her nose is amputated by Rama’s brother, Prince Lakshmana. The cultural significance of this act is that the nose is synonymous with respect. As a consequence, King Ravana orders her nose be reconstructed [7]. Although this legend leaves many details to the imagination, it highlights how commonplace such practices were. For example, in 1769 the Ghoorka King of India captured the city of Kirtipoor in modern day Nepal. He ordered the nasal mutilation of all 865 male inhabitants and changed the name to Naskatapoor, which translates to “city without noses” [8]. The cultural influence of more than three millennia of this practice is undeniable, exemplified by idiomatic expressions such “loosing face” which alludes to a loss of dignity and wonton embarrassment. In Urdu and Punjabi there is a colloquial expression “mera noc kart gaya” meaning “you have hurt my feelings”, but literally translated as “you have cut off my nose” [7]. It is therefore no surprise that nasal reconstruction is the oldest form of facial surgery. The first operative description of tissue translocation was performed by the Indian surgeon Sushruta (approximately 750–800 BC), considered by many historians to be the “Father of Indian Surgery”.